Venlafaxine extended release (XR) for the prophylaxis of migraine and tension-type headache: A retrospective study in a clinical setting

Efficacy of Desvenlafaxine in Reducing Migraine Frequency and Severity: A Retrospective Study

Background: Migraine is characterized by sudden acute episodes of pain, with a global prevalence of 18% among all age groups. It is the second leading cause of years lived with disability worldwide. Prophylactic treatment is important in managing migraine; however, its efficacy and safety are debated. This study aimed to evaluate the efficacy of desvenlafaxine in female patients with migraine. Methods: We conducted a retrospective observational case study involving 10 women diagnosed with migraine who were treated with desvenlafaxine. We measured the number of migraine days per month, average headache duration in minutes, headache severity using a visual analog scale, use of acute medications, and frequency of acute medication use per week. Results: Desvenlafaxine significantly reduced the number of migraine days from 14.70 ± 3.68 at baseline to 2.50 ± 2.50 at follow-up (p < 0.05). The average headache duration dropped from 131.25 ± 32.81 min to 52.50 ± 44.64 min. Headache severity scores improved from 6.80 ± 1.49 at baseline to 0.80 ± 0.92 at follow up, the frequency of acute medication use per week reduced from 3.30 ± 1.49 at baseline to 0.80 ± 0.92, and the frequency of acute medication use decreased from 3.30 ± 1.49 times per week to 0.80 ± 0.92. Conclusions: Desvenlafaxine shows potential as an effective prophylactic therapy for migraine. Larger-scale studies are necessary to further explore its benefits.

Management of Pain and Headache After Traumatic Brain Injury

This article will identify common causes of pain following traumatic brain injury (TBI), discuss current treatment strategies for these complaints, and help tailor treatments for both acute and chronic settings. We will also briefly discuss primary and secondary headache disorders, followed by common secondary pain disorders that may be related to trauma.

The Efficacy of Venlafaxine, Flunarizine, and Valproic Acid in the Prophylaxis of Vestibular Migraine

Background

Different types of medications are currently used in vestibular migraine (VM) prophylaxis, although recommendations for use are generally based on expert opinion rather than on solid data from randomized trials. We evaluated the efficacy and safety of venlafaxine, flunarizine, and valproic acid in a randomized comparison trial for VM prophylaxis.

Methods

Subjects were randomly allocated to one of three groups (venlafaxine group, flunarizine group, and valproic acid group). To assess the efficacy of treatment on vertigo symptoms, the following parameters were assessed at baseline and 3 months after treatment: Dizziness Handicap Inventory (DHI) scores, number of vertiginous attacks in the previous month, and Vertigo Severity Score (VSS). Adverse events also were evaluated.

Results

A decrease in DHI total scores was shown following treatment with all three medications, with no obvious differences between the groups. Treatment effects differed, however, in the DHI physical, functional, and emotional domains with only venlafaxine showing a decreased effect in all of three domains. Flunarizine and valproic acid showed an effect in only one DHI domain. Venlafaxine and flunarizine showed decreased VSS scores (p = 0 and p = 0.03, respectively). Although valproic acid had no obvious effect on VSS (p = 0.27), decreased vertigo attack frequency was observed in this group (p = 0). Venlafaxine also had an effect on vertigo attack frequency (p = 0), but flunarizine had no obvious effect (p = 0.06). No serious adverse events were reported in the three groups.

Conclusion

Our data confirm the efficacy and safety of venlafaxine, flunarizine, and valproic acid in the prophylaxis of VM, venlafaxine had an advantage in terms of emotional domains. Venlafaxine and valproic acid also were shown to be preferable to flunarizine in decreasing the number of vertiginous attacks, but valproic acid was shown to be less effective than venlafaxine and flunarizine to decrease vertigo severity.

Trial registration

ChiCTR-OPC-17011266 (http://www.chictr.org.cn/).

A Randomized, Double-Blind, Placebo-Controlled Study of Venlafaxine XR in Out-Patients With Tension-Type Headache

The aim of this study was to evaluate in a double-blind, randomized, placebo-controlled study the safety and efficacy of venlafaxine extended release (XR) in the prophylactic treatment of out-patients with tension-type headache (TTH) and no current depression or anxiety disorders. Sixty neurology and headache clinic out-patients meeting the International Headache Society diagnostic criteria for TTH were treated with venlafaxine XR (150 mg/day, n = 34) or placebo ( n = 26) for 12 weeks. The primary efficacy variable was the decline in number of days with headache. At end-point, the venlafaxine XR group had a significantly greater decrease in the number of days with headache compared with placebo ( P = 0.05). Differences with regard to secondary efficacy variables where not significant. The number needed to treat for responders (≥50% reduction in days with headache) was 3.48. Six patients in the venlafaxine XR group interrupted therapy due to adverse events, while no patients in the placebo group did so for the same reason. The number needed to harm was 5.58. This study provides preliminary evidence for the efficacy and safety of venlafaxine XR 150 mg/day in reducing the number of days with TTH.

Comparison of the Effects of Amitriptyline and Flunarizine on Weight Gain and Serum Leptin, C Peptide and Insulin Levels when used as Migraine Preventive Treatment

The tricyclic antidepressant amitriptyline (AMT) and the calcium channel blocker flunarizine are frequently used in the preventive treatment of migraine, but the side-effect of prominent weight gain that frequently emerges during preventive treatment of migraine with these agents often leads to the discontinuation of therapy. In this study, we aimed to investigate the possible relationship between the weight gain associated with the use of these agents and serum levels of leptin, C-peptide and insulin in patient with migraine. Forty-nine migraine patients with a body mass index (BMI) < 25 and without any endocrinological, immunological or chronic diseases were randomly divided into two groups, receiving AMT or flunarizine. There was a statistically significant increase in serum levels of leptin, C-peptide, insulin and measures of BMI in both groups when measured at the 12th week of therapy compared to their respective basal levels. To our knowledge this is the first study investigating the effects of AMT and flunarizine on serum leptin levels in preventive use of migraine treatment. A result from this study indicates that AMT and flunarizine may cause leptin resistance possibly by different mechanisms and thereby result in increase in serum leptin levels and BMI.

Venlafaxine in the treatment of anxiety disorders

Venlafaxine extended-release (Effexor XR, Wyeth-Ayerst Co.) is a novel, dual acting serotonin-norepinephrine reuptake inhibitor antidepressant, which inhibits the synaptic reuptake of both serotonin and norepinephrine. Controlled trials have demonstrated the efficacy and safety of venlafaxine in the treatment of anxiety disorders including social anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, panic disorder and obsessive-compulsive disorder. Generally well-tolerated with side effects that usually abate with continued treatment, venlafaxine is an important alternative to the selective serotonin reuptake inhibitors for patients with anxiety disorders.

The contribution of stress to the comorbidity of migraine and major depression: results from a prospective cohort study

OBJECTIVES

To assess how much the association between migraine and depression may be explained by various measures of stress.

DESIGN

National Population Health Survey is a prospective cohort study representative of the Canadian population. Eight years of follow-up time were used in the present analyses.

SETTING

Canadian adult population ages 18-64.

PARTICIPANTS

9288 participants.

OUTCOME

Incident migraine and major depression.

RESULTS

Adjusting for sex and age, depression was predictive of incident migraine (HR: 1.62; 95% CI 1.03 to 2.53) and migraine was predictive of incident depression (HR: 1.55; 95% CI 1.15 to 2.08). However, adjusting for each assessed stressor (childhood trauma, recent marital problems, recent unemployment, recent household financial problems, work stress, chronic stress and change in social support) decreased this association, with chronic stress being a particularly strong predictor of outcomes. When adjusting for all stressors simultaneously, both associations were largely attenuated (depression-migraine HR: 1.30; 95% CI 0.80 to 2.10; migraine-depression HR: 1.19; 95% CI 0.86 to 1.66).

CONCLUSIONS

Much of the apparent association between migraine and depression may be explained by stress.

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105-190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version.

Newer treatments for fibromyalgia syndrome

Fibromyalgia syndrome is a common chronic pain disorder of unknown etiology. The lack of understanding of the pathophysiology of fibromyalgia has made this condition frustrating for patients and clinicians alike. The most common symptoms of this disorder are chronic widespread pain, fatigue, sleep disturbances, difficulty with memory, and morning stiffness. Emerging evidence points towards augmented pain processing within the central nervous system (CNS) as having a primary role in the pathophysiology of this disorder. Currently the two drugs that are approved by the United States Food and Drug Administration (FDA) for the management of fibromyalgia are pregabalin and duloxetine. Newer data suggests that milnacipran, a dual norepinephrine and serotonin reuptake inhibitor, may be promising for the treatment of fibromyalgia. A double-blind, placebo-controlled trial of milnacipran in 125 fibromyalgia patients showed significant improvements relative to placebo. Milnacipran given either once or twice daily at doses up to 200 mg/day was generally well tolerated and yielded significant improvements relative to placebo on measures of pain, patient's global impression of change in their disease state, physical function, and fatigue. Future studies are needed to validate the efficacy of milnacipran in fibromyalgia.

Escitalopram and venlafaxine for the prophylaxis of migraine headache without mood disorders

There is evidence that some antidepressant drugs are beneficial in the prophylaxis of migraine. Previous reports have shown that migraine patients may respond to various antidepressant agents used for prophylactic therapy. The main purpose of this study was to compare the efficacy of antidepressants from 2 different groups (venlafaxine vs escitalopram) on people who had migraine headache without depression or anxiety. In this prospective study, we evaluated the headache diaries of 93 patients who were being treated with venlafaxine (n = 35) and escitalopram (n = 58). At the end of the 3-month period, patients were reassessed, and those with marked differences in attack frequency, duration, intensity (with visual analog scales), lost work-day equivalent index, and migraine disability assessment questionnaire were compared. There was a clear reduction in headache frequency (P < 0.0001), duration (P < 0.0001), and severity (P < 0.0001) in the venlafaxine group. In addition, there was a significant improvement in daily work performance during headaches (P < 0.0001). In the escitalopram group, monthly headache frequency (P < 0.026), duration (P < 0.002), and intensity (P < 0.027) all decreased significantly, although not to the same extent as with venlafaxine. After the third month of venlafaxine and escitalopram treatment, most of the patients (82.8% vs 96.5%) were seen to have moved to the minimal or infrequent migraine disability assessment group. According to our findings, venlafaxine and escitalopram are both effective in the prophylaxis of migraine headache without depression and anxiety. This effect was independent of mood disorder. Escitalopram should be the first choice because of its fewer side effects, but venlafaxine may be used if escitalopram is found to be insufficient.

Physician speciality and pain reduction in patients with depressive symptoms under treatment with venlafaxine

OBJECTIVES

Excessive pain perception may lead to unnecessary diagnostic testing or invasive procedures resulting in iatrogenic complications and prolonged disability. Naturalistic studies on patients with chronic pain and depressive symptoms investigating the impact of medical speciality on treatment outcome in a primary care setting are lacking.

METHODS

In this observational study, we examined whether the magnitude of pain reduction in 444 patients with depressive symptomatology under venlafaxine would relate differently to the medical speciality of the 122 treating physicians, namely psychiatrists (n=110 patients), general practitioners (n=236 patients), and internists (n=98 patients).

RESULTS

Independent of age, gender, patient's region of origin, comorbidity, severity and duration of pain, and depressive symptoms at study entry, patients seemed to benefit significantly less in terms of pain reduction (p<0.001) and of reduction in severity of depressive symptomatology by psychiatrists as compared to general practitioners (p<0.019) and internists (p<0.002).

CONCLUSIONS

The findings suggest that patients referred to psychiatrists are more difficult to treat than those referred to general practitioners and internists, and might not have been adequately prepared for psychiatric interventions. A supporting cooperation and networking between psychiatrists and primary care physicians may contribute to an integrated treatment concept and therefore, may lead to a better outcome in this challenging patient group.

Regional origin and decrease of pain in patients with depressive symptoms under treatment with venlafaxine

OBJECTIVE

Patient's language, tradition, conventions, and customs may all determine integration into a society and are also part of the doctor-patient relationship that influences diagnostic and therapeutic outcome. Language barrier and sociocultural disparity of Eastern and Southern European patients may hamper recovery from pain and depression compared to Middle European patients in Switzerland.

METHODS

In a prospective naturalistic observational trial we investigated the influence of regional origin on treatment outcome in 420 pain sufferers with depressive symptoms from all over Switzerland who were treated with venlafaxine by 122 physicians in primary care. Physicians rated severity of depressive symptoms using the clinical global impression severity scale and pain intensity by means of visual analogue scales. We hypothesized that in Eastern and Southern European patients the magnitude of pain reduction under treatment with venlafaxine is less compared to Middle European patients.

RESULTS

Three months after study entry, Middle European patients were found to profit more from treatment with venlafaxine in terms of severity of depression and pain intensity than patients from Eastern Europe and Southern Europe.

CONCLUSION

Regional origin may contribute to the magnitude of pain reduction in patients with depressive symptoms under treatment with venlafaxine. Our results provide a rational for care provider educational programs aimed at improving capacities in treating patients from different regional origin with psychosomatic complaints such as depression and comorbid pain.

Migraine preventive treatment

Migraine is a chronic neurological disease. Preventive therapy is given in an attempt to reduce the frequency, duration, or severity of attacks. Circumstances that might warrant preventive treatment include recurring migraine attacks that significantly interfere with the patient's daily routines, despite appropriate acute treatment; frequent headaches; contraindication to, failure of, overuse of, or intolerance to acute therapies; patient preference; frequent, very long, or uncomfortable auras; and presence of uncommon migraine conditions. The major medication groups for preventive migraine treatment include beta-adrenergic blockers, antidepressants, calcium channel antagonists, serotonin antagonists, and anticonvulsants. The choice of preventive treatment depends on the individual drug's efficacy and adverse events, the patient's clinical features, frequency, and response to prior treatment, and the presence of any comorbid or coexistent disease.

Fibromyalgia: an overview

Fibromyalgia is the diagnosis given to individuals with chronic widespread musculoskeletal pain for which no alternative cause, such as tissue inflammation or damage, can be identified. Fibromyalgia is now believed to be, at least in part, a disorder of central pain processing that produces heightened responses to painful stimuli (hyperalgesia) and painful responses to nonpainful stimuli (allodynia). Aberrations in central pain processing may also be partly responsible for symptoms experienced in several chronic pain disorders that coaggregate with fibromyalgia, which is itself a product of genetic and environmental factors. Thus, aberrational central pain processing is implicated in irritable bowel syndrome, temporomandibular disorder, chronic low back pain, and certain other chronic pain disorders. Fibromyalgia and related disorders appear to reflect deficiencies in serotonergic and noradrenergic, but not opioidergic, transmission in the central nervous system. The heightened state of pain transmission may also be owing to increases in pronociceptive neurotransmitters such as glutamate and substance P. In some cases, psychological and behavioral factors are also in play. Although the overlapping symptomatology between fibromyalgia and related disorders may present diagnostic challenges, proper examination and observation can help clinicians make an accurate diagnosis. In recent years, the vastly improved understanding of the mechanism underlying fibromyalgia and the related spectrum of diseases has fostered rapid advances in the therapy of these chronic pain disorders by both pharmacologic and nonpharmacologic interventions.

Understanding fibromyalgia: lessons from the broader pain research community

Fibromyalgia (FM) is a chronic pain condition marked by centrally mediated augmentation of pain and sensory processes. Skepticism has marked the history of this condition, but more recent study has identified neurobiological underpinnings supporting many of the symptoms associated with this condition. Early research in FM had unprecedented latitude within the rheumatology community to borrow heavily from theory and methods being applied in chronic pain research more generally. These insights facilitated rapid advances in FM research, not the least of which was the abandonment of a peripheral focus in favor of studying central mechanisms associated with central augmentation. Currently, rapid-paced discovery is taking place in FM genetics, patient assessment, new therapeutic targets, and novel methods of treatment delivery. Such insights are not likely to be limited in application just to FM and could have relevance to the broader field of pain research as well.

PERSPECTIVE

This manuscript reviews the history of FM and its diagnosis, evidence supporting central augmentation of pain in FM, potential mechanisms of central augmentation, current approaches to integrated care of FM, and areas of active collaboration between FM research and other chronic pain conditions.

Whites and African-Americans in Headache Specialty Clinics Respond Equally Well to Treatment

This study sought to determine if Whites and African-Americans respond similarly to headache treatment administered in ‘real-world’ headache specialty treatment clinics. Using a naturalistic, longitudinal design, 284 patients receiving treatment for headache disorders completed 30–day daily diaries that assessed headache frequency and severity at pretreatment and 6–month follow-up and also provided data on their headache disability and quality of life at pretreatment and 1–, 2– and 6–month follow-up. Controlling for socioeconomic status and psychiatric comorbidity, hierarchical linear models found that African-Americans and Whites reported significant reductions in headache frequency and disability and improvements in life quality over the 6–month treatment period. African-Americans, unlike Whites, also reported significant decreases in headache severity. Nevertheless, Africans-Americans had significantly more frequent and disabling headaches and lower quality of life after treatment relative to Whites. Although Whites and African Americans responded favourably to headache treatments, more efficacious treatments are needed given the elevated level of headache frequency that remained in both racial groups following treatment.

Pharmacotherapy and Lifestyle Interventions for Tension-Type Headaches

The objective of this review was to evaluate the efficacy of pharmacotherapy and lifestyle interventions for tension-type headaches. Literature was obtained through a MEDLINE (1966 to April 2008) search and a bibliographic review of published articles. Key terms searched included tension-type headaches, chronic tension-type headaches, pharmacotherapy, and lifestyle therapy. The search was further limited to the English language. Tension-type headaches are the most common and least studied primary headache disorder. These headaches are characterized by mild to moderate bilateral pain that is described as dull, aching, and bandlike. Episodic tension-type headaches may be treated with mild analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen; although treatment should be individualized, data suggest that NSAIDs may be considered first line. Chronic and frequent episodic tension-type headaches often require prophylactic therapy. Although tricyclic antidepressants are considered the drugs of choice for chronic tension-type headaches, preliminary trials with venlafaxine, mirtazapine, tizanidine, and topiramate have shown promise. Lifestyle interventions such as physical therapy, behavioral therapy, and acupuncture are often employed, despite the lack of sound clinical evidence to support their use. Preliminary data support the combination of a tricyclic antidepressant and behavioral therapy for chronic tension-type headache.

Optimizing prophylactic treatment of migraine: Subtypes and patient matching

Advances in our understanding of the pathophysiology of migraine have resulted in important breakthroughs in treatment. For example, understanding of the role of serotonin in the cerebrovascular circulation has led to the development of triptans for the acute relief of migraine headaches, and the identification of cortical spreading depression as an early central event associated wih migraine has brought renewed interest in antiepileptic drugs for migraine prophylaxis. However, migraine still remains inadequately treated. Indeed, it is apparent that migraine is not a single disease but rather a syndrome that can manifest itself in a variety of pathological conditions. The consequences of this may be that treatment needs to be matched to particular patients. Clinical research needs to be devoted to identifying which sort of patients benefit best from which treatments, particularly in the field of prophylaxis. We propose four patterns of precipitating factors (adrenergic, serotoninergic, menstrual, and muscular) which may be used to structure migraine prophylaxis. Finally, little is known about long-term outcome in treated migraine. It is possible that appropriate early prophylaxis may modify the long-term course of the disease and avoid late complications.

Management of chronic daily headache in children and adolescents

Chronic daily headache (CDH) occurs in 1-2% of children and adolescents. It can evolve from either episodic tension-type headache or episodic migraine, or can appear with no previous headache history. As with other primary headache disorders, treatment is based on the level of disability. There are children and adolescents who cope well, but there are others who are markedly disabled by their chronic headaches. As in adults, children and adolescents with CDH are at risk for medication overuse. CDH is a diagnosis of exclusion, based on a thorough history, normal physical examination, and negative neuroimaging findings. Along with the chronic headaches, children with this condition may have co-morbid sleep problems, autonomic dysfunction, anxiety, and/or depression. Principles of treatment include identifying migrainous components, stopping medication overuse, stressing normalcy, using rational pharmacotherapy, and addressing co-morbid conditions. Successful outcomes often involve identifying an appropriate headache preventative, reintegration into school, and family participation in resetting realistic expectations.

Efficacy of duloxetine as a migraine preventive medication: possible predictors of response in a retrospective chart review

OBJECTIVE

This case series is a retrospective chart analysis conducted to evaluate the efficacy of duloxetine as a migraine preventive medication and to suggest possible predictors of response.

BACKGROUND

Duloxetine, a relatively new selective serotonin and norepinephrine reuptake inhibitor, is FDA-approved for treatment of depression and diabetic peripheral neuropathic pain. The efficacy of duloxetine as a headache preventive medication is currently unknown.

METHOD

A retrospective chart review was performed using the electronic medical records of Headache Wellness Center, a headache specialty practice in Greensboro, North Carolina. From January 2004 to December 2006, 65 patients were identified who were prescribed duloxetine for migraine prevention for at least 2 months. Doses ranged from 30 mg qd to 90 mg qd. Frequency, severity, and impact of migraine disability were measured at baseline and compared to values obtained after 2 months of treatment.

RESULTS

The total patient sample demonstrated a reduction in mean monthly headache frequency from 19.40 (SD=7.1) to 15.70 (SD=8.2) (P= .01). The 50% responder rate was 22%. In subset analysis, individuals with abnormal baseline Zung anxiety scores demonstrated a greater reduction in mean monthly headache frequency (4.28, P= .03) and a greater responder rate (25%) than those in the total patient sample. Non-statistically significant trends were observed in those patients with abnormal baseline Zung Depression scores exhibiting a less robust mean monthly migraine reduction (2.75, P= .18) than those with normal baseline depression scores (3.42, P= .07).

CONCLUSIONS

Duloxetine demonstrates minimal effectiveness as a headache preventive medication. An interesting trend suggests that the presence of anxiety may be a positive predictor in treatment with duloxetine.

Future therapeutic perspectives for tension-type headache

The therapy for tension-type headache remains insufficient, and recent advances have been scarce. Although tricyclic antidepressants are at the forefront of treatment advances, upcoming agents tentatively modifying central sensitization are promising. Botulinum toxin failed to meet expectations. This article reviews current treatments, emphasizing newer approaches. Much remains to be achieved.

Pharmacological management of mood and anxiety disorders in headache patients

There is emerging evidence that treatment of comorbid mood and anxiety disorders can improve headache treatment outcome when implemented within a comprehensive program. Effective treatment for comorbid mood and anxiety disorders requires screening headache patients and accurately diagnosing specific psychiatric disorders when present. Specific dual-action antidepressant, anticonvulsant, and atypical antipsychotic medications can serve as dual agents that simultaneously treat both headaches and a mood or anxiety disorder. Serotonin reuptake inhibitors and most other antidepressant, anxiolytic, and mood-stabilizing medications are generally ineffective for headache prophylaxis. However, they can be safely added to a headache regimen for treatment of a comorbid psychiatric disorder. Treatment of comorbid psychiatric disorders in headache patients requires patient education about the psychiatric disorder, its treatment, possible side-effects, and expected benefits. Clinicians need to be sensitive to possible stigma that some patients fear from a psychiatric diagnosis or its treatment.

Facial flushing associated with duloxetine use

PURPOSE

A case of flushing associated with duloxetine use is presented.

SUMMARY

A 43-year-old nonmenopausal woman was prescribed duloxetine 20 mg daily for migraine prophylaxis after the usual medications for treatment and prevention of migraines were used with little or no success. Magnetic resonance imaging and computed tomography ruled out structural causes of migraines. The patient took 20 mg daily for five days and then decided, on her own, to decrease the dosage after experiencing insomnia, a common adverse effect of duloxetine. She opened the 20-mg capsules and took half of the contents to "create" the 10-mg dose, placing the contents of the opened capsule directly onto her tongue. She did this for two weeks and found the migraines to be significantly reduced in number and intensity. At that time, she began to experience what she described as a hot flash and facial flushing. The flushing was not accompanied by itching and did not spread beyond the face. The flushing occurred one to two hours after administering the 10-mg dose and typically resolved the following day. One week later, the patient noticed that the vessels in her face were more prominent. Concomitant therapies included pindolol for hypertension and duloxetine and botulinum toxin type A injections for migraines. The patient weaned herself off duloxetine. Facial flushing continued for one week after discontinuation of the drug. At a one-month follow-up visit, she stated that the flushing had resolved and not occurred since the original episodes.

CONCLUSION

A patient treated with duloxetine developed facial flushing, possibly caused by inappropriate administration of the drug.

Practical considerations for the treatment of elderly patients with migraine

Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.

Therapy Insight: fibromyalgia—a different type of pain needing a different type of treatment

In the past decade, we have made tremendous progress in our understanding of fibromyalgia, which is now recognized as one of many 'central' pain syndromes that are common in the general population. Specific genes that might confer an increased risk of developing fibromyalgia syndrome are beginning to be identified and the environment (in this case exposure to stressors) might also have a significant effect on triggering the expression of symptoms. After developing the syndrome, the hallmark aberration noted in individuals with fibromyalgia is augmented central pain processing. Insights from research suggest that fibromyalgia and related syndromes require a multimodal management program that is different from the standard used to treat peripheral pain (i.e. acute or inflammatory pain). Instead of the nonsteroidal anti-inflammatory drugs and opioids commonly used in the treatment of peripheral pain, the recommended drugs for central pain conditions are neuroactive compounds that downregulate sensory processing. The most efficacious compounds that are currently available include the tricyclic drugs and mixed reuptake inhibitors that simultaneously increase serotonin and norepinephrine concentrations in the central nervous system. Other compounds that increase levels of single monoamines (serotonin, norepinephrine or dopamine), and anticonvulsants also show efficacy in this condition. In addition to these pharmacologic therapies, which are useful in improving symptoms, nonpharmacologic therapies such as exercise and cognitive behavioral therapy are useful treatments for restoring function to an individual with fibromyalgia.

Headache

The patient who presents with headache can be diagnosed quickly and efficiently once the correct pattern has been identified. Most patients will have migraine, and treatment is based on the severity and disability. If the identified patient has significant disability, a medication that treats comorbidity should be prescribed. Patients who have a serious underlying disorder can be recognized by a thoughtful history and careful examination and can be worked up accordingly. Patients who have an acute new onset headache problem that requires immediate attention can be triaged and treated once their pattern and history are clear. Hopefully, increasing comfort levels with diagnosing headaches will allow the primary care practitioner to treat headache patients more effectively and efficiently.

Fibromyalgia: Progress in diagnosis and treatment

Fibromyalgia is a frequent cause of chronic widespread pain and affects up to 5% of the general population. Diagnosis and treatment have been especially challenging due to limited knowledge of etiology and poor response to conventional treatment of pain. Appreciation for the interactions of neurobiologic, psychologic, and behavioral factors in the disease pathogenesis has led to improved treatment options that can be effective in individual patients. Current evidence advocates a multifaceted program emphasizing patient education, medications for improving symptoms, and aggressive use of exercise and cognitive-behavioral approaches to retain or restore function.

Pharmacoprophylaxis of tension-type headache

Although tension-type headache typically is not as disabling as migraine, its chronic form may significantly impair patients' functional ability. The pathogenesis of tension-type headache remains largely unknown. Compared with migraine, tension-type headache is the object of much less research. For a number of years, research on headache therapy has vastly emphasized migraine. Even cluster headache, which is far less frequent than tension-type headache, has been subject to more therapeutic trials than tension-type headache. Therefore, it is not surprising that since the advent of studies (as early as 1964) on amitriptyline, which remains a pivotal treatment choice, the number of emerging treatments for this condition remains scarce, even in 2005. This emphasizes the need for renewed interest in this field. However, alternate treatment approaches, such as botulinum toxin injections, albeit controversial, have renewed hopes lately. In addition, recent progress in the understanding of tension-type headache pathophysiology, such as the role of peripheral and central sensitization, has revived interest in the field. This is a review of available, proven, or suspected prophylactic therapies for tension-type headache.

Comorbidity of major depression and migraine--a Canadian population-based study

OBJECTIVE

To estimate the prevalence of major depressive episodes (MDEs) in patients with migraine and to compare the strength of association with that of other long-term medical conditions.

METHODS

This study used a large-scale probability sample (over 130,000 sample) from the Canadian Community Health Survey (CCHS), a cross-sectional survey conducted by Statistics Canada. The CCHS screened for a broad set of medical conditions. Major depression was evaluated with the Composite International Diagnostic Interview Short Form for Major Depression, and the diagnosis of migraine was self-reported. The annual prevalence of major depression was calculated in the general population, in subjects with migraine, and in those with chronic conditions other than migraine.

RESULTS

The prevalence of major depression in subjects reporting migraine was higher than that in the general population or in subjects with other chronic medical conditions (17.6%, compared with 7.4% and 7.8%, respectively).

CONCLUSIONS

There is a strong association between major depression and migraine. The migraine-MDE association may account for a large fraction of the chronic condition-MDE association. The association between migraines and MDE differs from that of other chronic conditions, as the association persists into older age groups.